Provider Demographics
NPI:1437194156
Name:PEACHTREE IMMEDIATE CARE FP, LLC
Entity Type:Organization
Organization Name:PEACHTREE IMMEDIATE CARE FP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIK-ROE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-504-6392
Mailing Address - Street 1:3827 JIMMY LEE SMITH PKWY
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2630
Mailing Address - Country:US
Mailing Address - Phone:770-222-8900
Mailing Address - Fax:770-222-2757
Practice Address - Street 1:3827 JIMMY LEE SMITH PKWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2630
Practice Address - Country:US
Practice Address - Phone:770-222-8900
Practice Address - Fax:770-222-2757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003137060AMedicaid
GA003137060AMedicaid